In 2014, the clinic where I served as head of communications and digital strategy switched to a new online patient portal, a change that was mandated by the electronic health record (EHR) system we used. The company that provides the EHR system held several meetings for the COO and me to learn the new tool and provided materials to give to patients to help them register for and use the new portal.
As the sole person at my clinic working on any aspect of user experience, I knew the importance of knowing the audience when implementing an initiative like the patient portal. So I was skeptical of the materials provided to the patients, which assumed a lot of knowledge on their part and focused on the cool features of the portal rather than on why patients would actually want to use it.
By the time the phone rang for the fifth time on the first day of the transition, I knew my suspicion that the patient portal had gone wrong in the user experience stage was warranted. Patients were getting stuck during every phase of the process—from wondering why they should use the portal to registering for and using it. My response was to ask patients what they had tried so far and where they were getting stuck. Then I would try to explain why they might want to use the portal.
Sometimes I lost patients completely; they just refused to sign up. They had a bad user experience trying to understand how a portal fit into their mental model of receiving healthcare, and I had a terrible user experience trying to learn what I needed to do to guide patients through the migration. To borrow a phrase from Dave Platt, the lead instructor of the UX Engineering course I currently help teach, the “hassle budget” was extremely high.
I realized three important things in leading this migration:
- When people get stuck, their frustration prevents them from providing information up front. They start off with “I’m stuck” and don’t offer additional feedback until you pull it out of them. (If you felt a tremor just then, that was every IT support desk employee in the universe nodding emphatically.)
- In trying to get them unstuck, I had to employ skills that drew on my work outside of UX. There was no choice; I had a mandate to reach an adoption rate of at least 60%.
- The overarching goal was really to help these patients learn to do something different than what they were used to, whether that was deal with a new interface or deal with an interface for the first time at all.
Considering these three realizations led me to a single, urgent conclusion that has transformed my UX practice: user experience is really a way of defining and planning what we want a user to learn, so we also need to think about our own work as how to teach.
It follows, then, that user experience toolkits need to include developing a teaching mindset. But what does that mean? And what’s the benefit? Let’s use this patient portal story and the three realizations above as a framework for considering this.
Helping users get unstuck#section2
Research on teaching and learning has produced two concepts that can help explain why people struggle to get unstuck and what to do about it: 1) cognitive load and 2) the zone of proximal development.
Much like you work your muscles through weight resistance to develop physical strength, you work your brain through cognitive load to develop mental strength—to learn. There are three kinds of cognitive load: intrinsic, germane, and extraneous.
|This type of cognitive load …||is responsible for …|
|Intrinsic||Actual learning of the material|
|Germane||Building that new information into a more permanent memory store|
|Extraneous||Everything else about the experience of encountering the material (e.g., who’s teaching it, how they teach, your comfort level with the material, what the room is like, the temperature, the season, your physical health, energy levels, and so on)|
In the case of the patient portal, intrinsic cognitive load was responsible for a user actually signing up for the portal and using it for the first time. Germane cognitive load was devoted to a user making sense of this experience and storing it so that it can be repeated in the future with increasing fluency. My job in salvaging the user experience was to figure out what was extraneous in the process of using the portal so that I could help users focus on what they needed to know to use it effectively.
Additionally, we all have a threshold for comfortably exploring and figuring something out with minimal guidance. This threshold moves around depending on the task and is called your zone of proximal development. It lays between the spaces where you can easily do a task on your own and where you cannot do a task at all without help. Effective learning happens in this zone by offering the right support, at the right time, in the right amount.
When you’re confronted with an extremely frustrated person because of a user experience you have helped create (or ideally, before that scenario happens), ask yourself a couple questions:
- Did I put too much burden on their learning experience at the expense of the material?
- Did I do my best to support their movement from something completely familiar to something new and/or unknown?
Think about your creation in terms of the immediate task and everything else. Consider (or reconsider) all the feelings, thoughts, contexts, and everything else that could make up the space around that task. What proportion of effort goes to the task versus to everything in the space around it? After that, think about how easy or difficult it is to achieve that task. Are you offering the right support, at the right time, in the right amount? What new questions might you need to ask to figure that out?
Making use of “unrelated” skill sets#section3
When you were hired, you responded to a job description that included specific bullet points detailing the skills you should have and duties you would be responsible for fulfilling. You highlighted everything about your work that showed you fit that description. You prepared your portfolio, and demonstrated awareness of the recent writings from UX professionals in the field to show you can hold a conversation about how to “do” this work. You looked incredibly knowledgeable.
In research on teaching and learning, we also explore the idea of how we know in addition to what we know. Some people believe that knowledge is universally true and is out there to be uncovered and explored. Others believe that knowledge is subjective because it is uncovered and explored through the filter of the individual’s experiences, reflections, and general perception of reality. This is called constructivism. If we accept constructivism, it means that we open ourselves to learning from each other in how we conceptualize and practice UX based on what else we know besides what job descriptions ask. How do we methodically figure out the what else? By asking better questions.
Part of teaching and learning in a constructivist framework is understanding that the name of the game is facilitation, not lecturing (you might have heard the cute phrase, “Guide on the side, not sage on the stage”). Sharing knowledge is actually about asking questions to evoke reflection and then conversation to connect the dots. Making time to do this can help you recall and highlight the “unrelated” skills that you may have buried that would actually serve you well in your UX work. For example:
- That was an incredibly difficult stakeholder meeting. What feels like the most surprising thing about how it turned out?
- It seemed like we got nothing done in that wireframing session. Everyone wanted to see their own stuff included instead of keeping their eye on who we’re solving for. What is another time in my life when I had this kind of situation? How did it turn out?
All of this is in service to helping ourselves unlock more productive communication with our clients. In the patient portal case, I relied very heavily on my master’s degree in international relations, which taught me about how to ask questions to methodically untangle a problem into more manageable chunks, and listen for what a speaker is really saying between the lines. When you don’t speak the same language, your emotional intelligence and empathy begin to heighten as you try to relate on a broader human level. This helped me manage patient expectations to navigate them to the outcome I needed, even though this degree was meant to prepare me to be a diplomat.
As you consider how you’re feeling in your current role, preparing for a performance review, or plotting your next step, think about your whole body of experience. What are the themes in your work that you can recall dealing with in other parts of your life (at any point)? What skills are you relying on that, until you’ve now observed them, you didn’t think very much about but that have a heavy influence on your style of practice or that help make you effective when you work with your intended audiences?
Unlearn first, then learn#section4
When Apple wanted to win over consumers in their bid to make computers a household item, they had to help them embrace what a machine with a screen and some keys could accomplish. In other words, to convince consumers it was worth it to learn how to use a computer, they first had to help consumers unlearn their reliance on a desk, paper, file folders, and pencils.
Apple integrated this unlearning and learning into one seamless experience by creating a graphical user interface that used digital representations of objects people were already familiar with—desks, paper, file folders, and pencils. But the solution may not always be that literal. There are two concepts that can help you support your intended audiences as they transition from one system or experience to another.
The first concept, called a growth mindset, relates to the belief that people are capable of constructing and developing intelligence in any given area, as opposed to a fixed mindset, which holds that each of us is born with a finite capacity for some level of skill. It’s easy to tell if someone has a fixed mindset if they say things like, “I’m too old to understand new technology,” or “This is too complicated. I’ll never get it.”
The second is self-determination theory, which divides motivation into two types: intrinsic and extrinsic. Self-determination theory states that in learning, your desire to persevere is not just about having motivation at all, but about what kind of motivation you have. Intrinsic motivation comes from within yourself; extrinsic comes from the world around you. Thanks to this research and subsequent studies, we know that intrinsic motivation is vital to meaningful learning and skill development (think about the last time you did an HR training and liked it).
This appears in our professional practice as the ever-favored endeavor to generate “buy-in.” What we’re really saying is, “How do I get someone to feel motivated on their own to be part of this or do this thing, instead of me having to reward them or somehow provide an incentive?” Many resources on getting buy-in are about the end goal of getting someone to do what you want. While this is important, conducting this as a teaching process allows you to step back and make space for the other person’s active contribution to a dialogue where you also learn something, even if you don’t end up getting buy-in:
- “I’m curious about your feeling that this is complicated. Walk me through what you’ve done so far and tell me more about that feeling.”
- “What’s the most important part of this for you? What excites you or resonates with you?”
For the majority of patients I worked with, transitioning to a new portal was almost fully an extrinsically motivated endeavor—if they didn’t switch, they didn’t get to access their health information, such as lab results, which is vital for people with chronic diseases. They did it because they had to. And many patients ran into a fixed-mindset wall as they confronted bad design: “I can’t understand this. I’m not very good at the computer. I don’t understand technology. Why do I have to get my information this way?” I especially spent a lot of time on exploring why some users felt the portal was complicated (i.e., the first bullet point above), because not only did I want them to switch to it, but I wanted them to switch and then keep using the portal with increasing fluency. First I had to help them unlearn some beliefs about their capabilities and what it means to access information online, and then I could help them successfully set up and use this tool.
While you’re researching the experience you’re going to create around a product, service, or program, ask questions not just about the thing itself but about the circumstances or context. What are the habits or actions someone might need to stop doing, or unlearn, before they adopt what you’re creating? What are the possible motivators in learning to do the something different? Among those, what is the ratio of extrinsic to intrinsic? Do you inadvertently cause an inflammation of fixed mindset? How do you instead encourage a growth mindset?
Where we go from here#section5
Ultimately, I hit the target: about 70% of patients who had been using the old portal migrated to the new tool. It took some time for me to realize I needed to create a process rather than react to individual situations, but gradually things started to smooth out as I knew what bumps in the road to expect. I also walked back even further and adjusted our communications and website content to speak to the fears and concerns I now knew patients experienced. Eventually, we finished migrating existing patients, and the majority of patients signing onto this portal for the first time were new to the clinic overall (so they would not have used the previous portal). To my knowledge the interface design never improved in any profound way, but we certainly lodged a lot of technical tickets to contribute to a push for feature changes and improvements.
Although this piece contains a lot of information, it essentially boils down to asking questions as you always do, but from a different angle to uncover more blind spots. The benefit is a more thorough understanding of who you intend to serve and a more empathetic process for acquiring that understanding. Each section is specifically written to give you a direct idea of a question or prompt you can use the next time you have an opportunity in your own work. I would love to hear how deepening your practice in this way works for you—please comment or feel free to find me on Twitter!
8 Reader Comments
This is fantastic, thank you Aimee for a very insightful look into UX.
I’m curious if the medical portal changed in essence of forms and functionality or was it aesthetic in nature?
I really related to the fixed mindset situation as developer, being that I’ve used a chat box on our site to interact with the audience.
Stay smart Aimee,
Finding someone who will give advice or express your opinion is not so difficult. It is much more difficult to find someone who is not always able to be in the foreground, loves and knows how to listen to others. He maintains eye contact and devotes all his attention to the instructor. You can often help by simply listening and asking thoughtful questions. Pronouncing his own thoughts, sharing his feelings, a person examines himself and understands the situation with minimal interference. If he feels understood and accepted, he is more inclined to ask for advice in the future. A good mentor does not think that his point of view is the only correct one, and the ways to solve problems are the best possible. Nor does he seem to need to save those who are being instructed. Mentors, guided by a sense of respect and dignity in a relationship, are able to gain confidence. The ideal mentor is already a person in life who does not need to assert himself at the expense of inexperienced and young people.
I’m so sorry for the long delay in responding! I’m glad you enjoyed reading this work. 🙂 To my knowledge the portal was very, very slow in changing in terms of functionality or aesthetics (it was running on Microsoft Silverlight, which just about killed me). They may have modified it since I was working on this migration, but my guess is it would be very subtle since the primary stakeholders were the Electronic Health Record vendors, not the patients themselves–a sign of a very dysfunctional system, to be sure.
I bet that fixed mindset issue resonates as a dev! Hopefully this helps you help audience members communicate with you more effectively so you can do your part to assist them better.
You make a good point — ego coupled with the lack of self-awareness make mentoring and teaching (and therefore good design) difficult. Being able to make space for someone else’s learning is a practice, not an end game, so keeping your eye on that ideal is awesome knowing that you’ll work at it daily. 🙂
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